Laparoscopic approach for a cesarean scar pregnancy.

OBJECTIVE: To describe a surgical technique of laparoscopic resection of a cesarean scar pregnancy (CSP) with an immediate myometrial reconstruction. The advantage of such a technique is that it is a minimally-invasive procedure that can treat the ectopic pregnancy and the defected scar at the same time with good postoperative results. DESIGN: Video article with the description of a surgical minimally-invasive technique. SETTING: Academic medical center. PATIENT(S): A 34-year-old patient, Gravida 6 Para 4 Abortus 1, with a history of 4 previous cesarean sections presented to the emergency department with abdominal pain and vaginal bleeding. The patient was hemodynamically stable. An endovaginal ultrasound revealed a viable pregnancy of 8 weeks implanted in the cesarean scar, with a residual myometrium of <1 mm. Because of increasing abdominal pain, vaginal bleeding, and a desire to preserve future fertility, an emergent laparoscopy was performed. INTERVENTION(S): Laparoscopy was performed using a CO2 AcuPulse laser device (Lumenis Inc. Salt Lake City, Utah). A continuous wave mode was used, with a power of 30 Watt and a round-shaped beam of 1.5 mm in diameter. The laser was connected to a 10-mm Hopkins endoscope 0° (Karl Storz, Tuttlingen, Germany). A complete adhesiolysis was performed, and the urinary bladder was detached from the anterior abdominal wall. The vesicouterine fold was opened to expose the isthmic part of the uterus where the ectopic pregnancy was implanted. The defected scar was resected en bloc with the pregnancy, using the laser. The limits of the resection depended on the residual myometrial thickness. We considered a myometrial thickness of >8 mm as healthy tissue. A metallic probe was introduced vaginally into the endocervix to differentiate the anterior part from the posterior part of the uterus. This probe facilitates the manipulation of the cervix and, thus, the laparoscopic intracorporeal suturing during the myometrial reconstruction. A 2-layered suturing was performed. The first layer of the suture consisted of 3 interrupted figure-of-8 sutures using a monofilament absorbable suture (Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). A second superficial layer consisted of a continuous nonlocking suture using the same type of thread. MAIN OUTCOME MEASURE(S): Laparoscopic excision of the CSP and immediate repair of the scar defect without any postoperative complications. RESULT(S): An emergent laparoscopy was performed, with excision of the CSP and immediate reconstruction of the residual myometrium. No complications occurred, the blood loss was estimated at 200 mL, and no blood transfusion was necessary. The patient was discharged 24 hours after the intervention. Six months after surgery, the remaining myometrial thickness was between 7 mm and 9.3 mm, and no residual cesarean scar defect (isthmocele) was visualized by ultrasound. CONCLUSION(S): Cesarean scar pregnancy is a rare form of ectopic pregnancy. The incidence, however, is increasing as a consequence of the rising cesarean section rate. Different surgical and nonsurgical techniques have been described in the literature. Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction. The cesarean scar defect diminishes, and this potentially could improve the future fertility of the patient and decrease the probability of abnormal uterine bleeding and chronic pelvic pain.

Advanced Interventional Procedures after Intrauterine Tamponade Balloon Insertion in a Tertiary Care Center.

OBJECTIVE: To evaluate the rate of success and practicability of the intrauterine tamponade balloon (ITB) for managing PPH as a fertility-sparing tool. Methods: a five-year retrospective monocentric study in a tertiary care center including patients transferred for severe PPH. Results: In 231 patients, the success rate of ITB (n = 57), embolization (n = 58), and medical management (n = 114) was 84.21%, 74.13%, and 76.32%, respectively. Cesarean section during labor did not influence the risk of advanced interventional procedures (AIPs) for patients with ITB (odds ratio [OR] = 1.08) but did so in patients who were under expectant management in the intensive care (OR = 5.29). In the AIP subgroup of the ITB group, hemostasis was significantly deteriorated. Prothrombin time <50% (OR = 11.5), fibrinogen <2 g/L (OR = 6.88), and >4 red blood cells units (RBCs) transfused (OR = 17.2) were associated with a significantly higher risk of failure. Blood loss in the AIP patients in the embolization group was significantly higher. Patients requiring >4 units of RBCs were 22.9 times more likely to have an AIP (p = .0001). Conclusion: Compared with uterine embolization and medical management, ITB use in a tertiary care center was associated with lower risk of undergoing AIP, but further prospective study is required to confirm this.